Ablation

Ablation

by Gemita - 2021-11-10 07:35:19

Beattie, hello.  How are you?  

I suffer intermittently from multi focal atrial tachycardias, coming from many abnormal atrial pacemaker sites within the heart.  For me these are often triggered by my atrial tachy arrhythmias, like Flutter, Afib and also premature atrial contractions.  

My EP/cardiologist suggested that by increasing my base rate from 60 - 70 bpm this might help since I had evidence of bradycardia induced arrhythmias. I believe they call it Atrial overdrive pacing to try to suppress tachycardia.  Maybe this is what your doctors want to try?  They felt by increasing my base rate I might see a reduction in all my arrhythmias since this would serve to outpace any slow, irregular rhythms and keep my heart rhythm steady.  I have to say Beattie for me this has been a successful means of managing my arrhythmias and I have seen a noticeable reduction in ectopic beats too (for me these nasty frequent beats were often the triggers for many of my atrial tachyarrhythmias and ventricular ones too).   It doesn't work for everyone though, but it works well for me.

I would try perhaps the increase in base rate first (nothing to lose) before going down the ablation route.  Have you had a regular pulmonary vein isolation ablation where they map out where the foci are coming from during an EP study and then ablate around the pulmonary veins or other specific areas?  Oh I see you have had several ablations already.  An AV ablation would be final Beattie and in my opinion should only be considered when all other options have been tried or when you are so symptomatic with high heart rates that cannot be controlled with medication.  I presume your doctors have looked for other causes, like infection, electrolyte changes, since my multi focal AT started at the time of my exposure to Coronavirus (April 2020) and continued for months and still happening intermittently.

In early 2017 I had an electrophysiology (EP) study done to look for any substrate for AV nodal reentry tachycardia and to see if suitable for Flecainide.  IV Flecainide was administered during my EP study which stopped my AFib episode, after the failure of 3x cardio versions.  I hadn't consented to an ablation prior to my Study, so they didn't do one.  I am now off Flecainide and only on low dose Bisoprolol and an anticoagulant and my arrhythmias are well controlled.  So that was my experience.

Whatever you do, please take your time.  Try not to panic.  It will only make your arrhythmias worse.  Please let me know if I can help in any way.

Site of Arrhythmias.?

by Marybird - 2021-11-10 09:22:17

Beattie,, I see from your history that you've had a number of ablations already and a history of multiple arrythmias,, and are wondering ( understandably), where to go from here. Poor thing, your history sounds so much like my daughter's, she has gone through similar experiences with the incessant tachycardia, poor response to medications, and multiple ablations. One of those ablations ( the first one), was a PVI for afib, fortunately her afib has not recurred. She had what seemed like several foci of atrial tachycardia, as well as sinus tachycardia. At the time her incessant tachycardia ( resting heart rate of 130, would go up from there with any activity) was believed to becoming from her sinus node, and she had her sinus node completely ablated ( in two ablations, the EP was reluctant to ablate it completely, but the first ablation didn't stop the tachycardia), and that made her pacemaker dependent.

After that they finally were able to identify one or two other atrial foci as sources ( other than the sinus node) of tachycardia, but were unable to get to those from ablating inside the heart, due to the proximity of the phrenic nerve ( she had had one ablation where someone actually did zap the nerve, resulting in some mild diaphragmatic paralysis-, fortunately, that nerve regenerated). They were able to ablate those areas, from outside her heart, through a thoracotomy ( in the side in between the ribs), this avoided the phrenic nerve and resolved the tachycardias in those areas. She still has some tachycardia at times, but she says it's mild and doesn't occur all that often. She's pacemaker dependent after the sinus node ablation, but all in all ( after close to 10 years with it), she's grateful she got her life back. 

About the ablations. I don't think I saw a mention of afib in your post, or your history, and it's my understanding that PVI isolation ablations are done for afib. For other atrial tachy-arrhythmias,, as I was told by my EP, they identify the site of origin and ablate that, and it sounds as though you have gone through that quite a bit already. As I recall, in my daughter's case after her arrhythmias returned with a vengeance after her sinus node ablation, and several atrial ablations, we all discussed the possibility of an AV node ablation. But like you, her EP ( and the rest of us) were very reluctant to do that because of her age ( she was about 29 at the time). Fortunately they were able to find and ablate ( from the outside of her heart), the main atrial trouble spots. 

As for a sinus node ablation, I'm under the impression that this is not done anymore, and certainly would not be if the tachycardia is not coming from the sinus node. You mention a history of IST, so that could be an issue. But there is at least one medication out there that specifically targets the electrical pathways for the sinus node, and this medication( Corlanor, generic name ivrabidine)  is reported to be successful in controlling inappropriate sinus tachycardia. This medication was not available in the US at the time my daughter could have used it, it was marketed here later as a medication for heart failure and used off label for IST. At that time the EP prescribed it for my daughter ( who was having some heart failure issues that have since resolved) and she said it helped. She no longer takes the medication, doesn't need it. 

 I know it's a difficult journey for you, and you have my best wishes that you'll find a light at the end of that tunnel. Mary

Have you had a recent EP Study ?

by Gemita - 2021-11-10 10:08:28

Beattie, after reading Marybird’s helpful, detailed post, I wonder whether you would benefit from another EP Study to assess where we are now and to look for further trigger areas or areas that may need redoing unless this has recently been done?  An EP Study without an ablation isn’t often carried out but it can be a good way to determine the best treatment. Our electrical disturbances are changing all the time reflecting changes in our health, medication, pacing and it is often necessary to look again and again for new trigger areas which may not have been picked up previously.  Lots to think about I know.

Have your arrhythmias noticeably increased since your second pacemaker for pain control or has your pain increased?  A few checks from your general doctor looking for other causes for worsening arrhythmias might help before making any final decisions.  My EP wasn’t at all surprised when I developed Multi Focal Atrial Tachycardia during my illness with Coronavirus.  I have shared by private message my EP's comments when I was considering an AV Node ablation just in case it helps.

I wish you well Beattie

Mary, my understanding is that the pulmonary veins are a common source for both AFib and regular Atrial Flutter.  I was told that following an ablation around the pulmonary veins for AFib, there was the potential for worsening symptoms (pro arrhythmia in the form of Atrial Tachycardia and/or regular Flutter to occur) which may be very difficult to treat. One of the reasons why I didn't proceed to an ablation.  I knew what I had, not what I might get.  For me it was the right choice.  If things deteriorate in the future, I will probably skip the regular ablation and move straight to an AV Node ablation since I have AFib with a rapid ventricular response rate and am extremely symptomatic during episodes.  

Atrial Flutter

by Marybird - 2021-11-10 17:36:46

Gemita, I've heard it said (and read) also that sometimes afib ablations, done typically with pulmonary vein isolation, result in post-ablation a-flutter, or as you mentioned, atrial tachycardia, often multifocal. I don't know the mechanisms by which these arrythmias occur post afib ablation, but it seems they don't occur in the same sites where the afib was ablated.

I've posted several links explaining ablations in general and the types ( or locations) of ablations for a-flutter. Apparently these are considered "easy ablations" (at least the typical a-flutter, atypical being more complicated) as their sites of activation are typically found in one of 2-3 locations (not around the pulmonary vein) and can easily be ablated. The a-fib.com site has a great explanation of both typical and atypical a-flutter ablations.

From what I've read, though, pulmonary vein isolation ablations are limited to afib, and atrial tachycardia can originate from anywhere in the atria, in single, or multiple foci, and those sites must be located, and the tachycardia initiated, in order to ablate them. The EP that put in my pacemaker told me, after reviewing all the monitor reports I'd had showing the tachycardia ( that I'd always assumed was AVNRT), he believed it was atrial tachycardia, and since it was paroxysmal in nature, and more or less controlled with the medication, he was reluctant to ablate it. He said that AT can be difficult to induce in the EP lab, and sometimes attempts to ablate a site where you saw it last ( till the tachy stopped) gets nowhere, sometimes irritates another site, causing another AT site ( his description sounded like "Whack-A Mole" to me, and I saw that happen to my daughter during some of her many ablation), so I agreed with his opinion that it might be better to treat my AT medically, with a pacemaker if needed- especially since the bradycardia seemed to have a life of it's own without the medication sometimes. However, with improvements in ablation techniques and new equipment, he said AT can be ablated if it can be induced, so I guess it can be successful.

But how many times does anyone want to go through ablation, especially if another AT may pop up at any time, and we learned through my daughter's many travails through this that any myocyte ( cardiac cell) anywhere in the heart can become a "pacemaker", ie, can send out an electrical signal to initiate a heartbeat, so arrhthymias/tachycardia can initiate anywhere in the heart- no fun trying to chase those all over!

I'd probably go right to an AV node ablation too in your shoes, especially with very symptomatic AT's, a-fib and whatever else doing a very serious number on your quality of life.

https://a-fib.com/faq-a-fib-and-the-two-types-of-a-flutter/

https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/atrial-flutter-ablation

https://www.webdicine.com/types-of-ablation-surgery.html

thanks!

by Beattie - 2021-11-10 17:59:08

Wow what useful info thanks very much Gemita and Marybird. 

I haven't had the Pulmonary Vein Isolation as I don't have Afib,  just Atrial Tachy and Sinus Tachy. 

I have been taking Ivabradine 10mg twice daily since it was a brand new drug in Australia and did help reduce resting my heart rate ( they had to get approval from Drug company to use high dosage at the time) I am also on Diltiazem and Digoxin... have had 7 EP studies only 3 where they were able to induce and ablate arrythmia's First one was for  AV Nodal re-entry Tachy  ... And the others were in different areas of the Atria.  My last EP study was in 2016 under GA instead of sedation but they could only induce Sinus Tachy.... Have given them a break now for a bit I was getting a bit sick of them 🥴 and not getting anywhere. 

Will keep you all posted as to how we go... 

Beattie and Marybird

by Gemita - 2021-11-10 18:46:32

Beattie, I know, really frustrating when they cannot induce an arrhythmia during an EP Study and you have had more than your fair share of them, haven't you.  I was in Afib at the time of mine and they couldn't stop it so perhaps I was lucky.  I wonder what they would uncover if you had longer term monitoring?  I also took Digoxin (with Flecainide), both triggered worsening symptoms for me in the end and I am better off on beta blockade alone.  Your comment "not getting anywhere" says it all and tells me you may have exhausted all options ablation wise, except for AV Node ablation.  Anyway there are many patients who have had successful AV Node ablations and who are doing well, so don't lose hope for a good outcome.

Mary many thanks for the links.  I will read them tomorrow and let you have my thoughts.  My EP whenever I try to pin him down to describe the nature of the arrhythmia seen and recorded by my pacemaker, would often say he places all my atrial tachy arrhythmias under one umbrella since my Afib can deteriorate rapidly into multi focal atrial tachycardia and then switch to Atrial Flutter the next moment.  He has already told me I would need at least two regular ablations to try to stop my Afib.  I know that one arrhythmia can frequently hide behind or unmask another, so there is no knowing what they would uncover.  Better to keep things as they are Mary for as long as I can. 

Goodnight to both of you

Ablation

by AgentX86 - 2021-11-10 23:18:34

PVIs are common for typical ALF, too.  Often the re-entrant path is around the pulmonary vein.  These would be very high rate atrial contractions (300bpm or even above).  Other paths are certainly possible but usually show lower flutter rates (longer path length around the heart). There are really two different versions of atypical AFLs.  One is where the re-entrant signal goes around its path in the opposite direction of what's "typical".  The other is when the path is in the left atrium, rather than the right.  This is more difficult to ablate.

As Gemita said, make sure there is no other choice before you go for an AV ablation.  It's forever. Being pacemaker dependent isn't a huge deal.  Many of us are.  Ablating the AV node can be thought of as an intentional heart block. No one wants that either.

Before giving up, you should have one of the best ablation EP take a look at your records anyway.  You need someone who does these procedures for a living.  Find someone who has done a thousand ablations and at least a hundred per year.

I've had an AV ablation but not before trying everything else.  I had a Cox Maze go wrong which left me in permanent atypical flutter.  Nothing short of ameoderone would touch it and that's certainly not a permanent solution, particularly at your age. Three ablations failed and my EP said it wasn't worth another try.  It was where it couldn't be ablated.  I'm twice your age and my EP wouldn't keep me on it for more than six months.  Even then, it damaged my thyroid (since recovered).

Bottom line, try everything else first.  If you still can't stand living with it then an AV ablation may be the best solution.  An AV ablation is really a quality of life decision.

Quality of life!

by Beattie - 2021-11-11 06:01:50

thanks AgentX and Gemita your encouragement not to give up certainly helps! I am thankful for a very good long suffering Cardiologist and the EP who placed both my Pacemakers in has also been a lot of help. 

My cardio and EP are an excellent team and are going to have a meeting to see what they can come up with after a further conversation with the EP today... My young age is a bit of the spanner in the works, I have been on amiodarone low dose for years as well ( it was the second drug that was ever put on ) it's been the only thing that has been somewhat effective but I am well aware of the dangerous side effects it can have so we have given it a break for the moment... we are trying to do all we can without the use of it! I just wish there was something out there as effective with less side effects!! The drug combos I have tried are endless! 

With daily tachycardia quality of life is definately affected, it wears you down after a while!!

 The very first cardiologist I saw in 2006  was rather disinterested, brushed me off gave me a script for Digoxin saying give it 6 months and you will be right... And here we are 15 years later!! 🤕

Trust yourself

by Gemita - 2021-11-11 18:53:15

Beattie, looking at your history, I see you have been diagnosed with  “autonomic dysfunction”?  I have vasovagal intermittent swallow syncope which my neuro-gastroenterologist/EP believe is a strong trigger for my arrhythmias and so do I.  Gastric issues frequently are.  I am now having treatment for both my swallowing difficulties and my arrhythmias and this combined treatment is really helping but it has been a long frustrating journey. Your situation sounds complex too with IST but I have no doubt you are getting closer to finding a solution.  You certainly know by now what works and what doesn’t so you can move forward with confidence to the next stage of your treatment.

With daily tachycardia, I can imagine it is wearing you and your heart down and the earlier you can stop this, the better.  I was also offered Amiodarone because I was told “it works”.  I chose Flecainide and Digoxin but neither really helped and actually caused worsening arrhythmias by slowing conduction through the AV Node.  The best treatment for me so far has been my little device which keeps my heart rate up.  Certainly works better for me than any anti arrhythmic med ever did.  Who would ever have thought it?   

I hope you will soon find what works best for you since with arrhythmias and complex health issues, it can be trial, error and disappointment a lot of the time.  Coming to terms with our condition and making a decision on how best to manage it, particularly if a cure is difficult to achieve, can be very therapeutic in itself.  My personal struggles initially with the fear of having to take lifelong anticoagulation, then needing either a pacemaker or an ablation, caused such stress and anxiety.  I am glad the struggle is over, I have faced and overcome all my fears, the right decision was made and I am finally able to move forward.  I hope it will be the same for you too